Evaluating the state of the NHS in its seventh decade is the subject of this book. It specifically addresses the programme of reforms undertaken by the Coalition government (2010–2015) in England. Our particular focus is from a policy perspective. This book adds to the growing body of knowledge about the design and implementation of major health service reforms in the UK (for example, Greener et al, 2014). Although it takes as its specific focus the five year period of the Coalition government (between the Conservatives and the Liberal Democrats; 2010–2015), it sets these reforms within a wider social, political, financial and organisational context of reforms to the NHS over the previous 25 years.

When a major reform of the National Health Service is announced, it is often claimed to be the most significant, the most far-reaching, the most consequential re-organisation that has taken place since its inception in 1948 (for example, Margaret Thatcher's foreword to Working for Patients, Secretaries of State, 1989). Indeed this may be so. Yet the reforms of the Coalition government, whose apogee was the 2012 Health and Social Care Act, can truly meet this oft-quoted claim. In a speech in November 2010, David Nicholson, the then NHS Chief Executive, referred to these reforms as ‘such a big change management, you could probably see it from space’ (quoted in Greer et al, 2014, 3). Moreover, not only were they major health policy reforms in their own right, but they built on a series of successive pro-market reforms which date back to the mid-1980s.

Yet the scale of re-organisation was not mentioned in the Conservative party's manifesto (for the 2010 general election); instead, its emphasis was on decentralisation of power to clinical staff (including GPs) and enhancing autonomy for NHS providers. For example: ‘We will decentralise power, so that patients have a real choice. We will make doctors and nurses accountable to patients, not to endless layers of bureaucracy and management’ (Conservative Party, 2010, 45).

Nor did the Coalition partner, the Liberal Democrats mention largescale NHS reform in their 2010 election manifesto. For example: ‘We all know that too much precious NHS money is wasted on bureaucracy, and doctors and nurses spend too much time trying to meet government targets’ (Liberal Democrats, 2010, 40).